APPLICATION FOR HPCL LPG Energy Solution Providers and Suppliers (ESPS)

(FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN)

D D / M M / Y Y Y Y

Office Code Serial No. Date of receipt of application Passport size

photograph with
Particular of Application Fees Rs specimen signature of
Demand Draft Number Date / / applicant on photograph

Drawn on (name of the bank) Payable At

In favour of ( Full name of the oil company)

Application processing fee of Rs10000/- (Ten thousand only) to be enclosed by all applicants applying for ESPS distributorship.

1 Name of the Location

2 Rev. Dist.
3 State

4 Advertised on DATE / / IN
D D M M Y Y Y Y Name of News Paper

5 Status Individual/ Partnership/LLP/Regd. Co-operative Society/Organised body (Tick as applicable)

7 Individual : ( Individuals to enclose Affidavit as per Annexure ‘A1’)

7.1 Name of applicant( First name , Middle

name, Surname

Father/Husband Name ( First name ,

7.2 Middle name, Surname

7.3 Address

Mobile no. Pin code

E-mail ID `

7.4 Nationality Resident of

Persons other than Indian Nationals are not eligible Name of town

7.5 GENDER Revenue District

MALE/FEMALE State

7.6 Date of Birth / / Age Yrs. Month Days

Attach copy of proof of date of birth Age as on the date of advertisement
AADHAR NUMBER PAN NUMBER

7.7 Marital Status Single / Married / Widow / Divorcee Tick as applicable

8 For being eligible, the applicant should have sound Physical / Mental health. Are you YES / NO
having sound Physical / Mental health ? Strike off what is not applicable.

Name of location : Signature of Applicant

Contd. to page no.2

 APPLICATION FOR HPCL LPG Energy Solution Providers and Suppliers (ESPS)
(FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN)

9 Educational Qualification*
(Attach copy of proof of Educational Qualifications) (*) –Not applicable in case of Registered Societies, Corporates, Govt Organisations etc.

Qualification Certificate/Degree Board/University Year of Passing

a SSC/Matric or Equivalent
b Graduate
c Post Graduate
d Professional Degree
e Additional Qualifications
Note : Marks will be awarded based on the information given by the applicant on the education qualification. On verification if it is found that the
information given above is incorrect/ false / misrepresented then the applicant's candidature will stand cancelled and will not be eligible for

10 In case of partnership, please give name of each of the partners and attach Proposed Partnership Deed. Application of all the partner(s) should
be attached together while submitting: (Please note each partner will have to pay separate application fee and all the partners will have to
appear for interview.)
Sr. No. Names and Address % Share
i)
ii)
iii)

10* Registered. Society/LLP/ Government Organisations / Corporations / Undertakings, Public LTD. Companies, and Companies incorporated under
Companies Act 1956 (Enclose affidavit as per Annexure ‘A2/A3’)
Name
Address

PIN CODE
Mobile No. E-MAIL ID
CIN/TIN/GST NUMBER

11 Experience: For ESPS, the applicant should have work orders with successful completion certificate of at least 5 installations having a cylinder
bank of minimum 20 x20 cylinders, in the last three years from the date of advertisement.
Name and address of the Details of conversion Converted from HSD/FO/etc. Monthly
establishment/Institution etc. From To Consumption in
LPG
LPG
LPG
LPG
LPG
LPG
Add details of the number of installations where conversions have been carried out.Add Separate sheets for more customers along with supporting

Note :Marks will be awarded based on the information given in the application. On verification if it is found that the information given is incorrect/
false / misrepresented then the applicant's candidature will stand cancelled and will not eligible for ESPS selection.

12 Have you ever been convicted or charges have been framed by Court of Law for any criminal offence involving moral YES NO
turpitude and / or economic offence (other than freedom struggle)? ? Please strike off what
is not applicable
(If yes you are not eligible to apply.)

Name of location : Signature of Applicant

Contd. to page no.3

 APPLICATION FOR HPCL LPG Energy Solution Providers and Suppliers (ESPS)
(FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN)

13 Capability to Provide Infrastructure as on the Date of Application(Applicable only for ESPS)

13.1 GODOWN FOR STORAGE OF LPG CYLINDERS: The land should be suitable, in contiguous plot, freely accessible through all-weather motorable
approach road. The plot should be free from overhead power transmission and telephone lines. Pipelines / Canals / Drainage /Nullahs / Public
Roads should not pass through the plot.
13.1a Do you have a suitable land within the advertised location for LPG godown or LPG godown readily available YES NO
Owned/Leased (Minimum 5 years from the date of advertisement) in your own name or in name any member of your Please strike off what
‘Family Members’ or Cooperative Society/Firm/Company.(Select what is applicable) is not applicable
Note :(‘Family members’, shall consist of applicant, his/her Spouse and their son(s)/daughter(s), Father,Mother,Father in Law,Mother in Law,

If Yes to 13.1a, Provide the following details and attach affidavit if the land for showroom is offered by a Family Member/Firm/Company.
Land Owner Relationship Date of registration of sale Address of the location of Khasra no/ Dimension Dist. form
with applicant deed/mutation/gift /lease the land for LPG Godown Survey No. ( L & B) in advt. loc. in

If No to 13.1a, then
13.1b Do you have a Firm offer of sales/ Lease (Minimum 5 years from the date of advertisement) from any owner of a YES NO
suitable land at within the advertised location for LPG godown or LPG godown Please strike off what
is not applicable

If Yes to 13.1b, Provide the following details.

Land Owner Date of agreement to sale or lease on Address of the location of Khasra no/ Dimension Dist. form
stamp papers the land for LPG Godown Survey No. ( L & B) in advt. loc. in

If No to 13.1b then
13.1c If you do not have a suitable piece of land for Godown and do not have firm offer, can you arrange the same in the YES NO
location advertised, if selected within 45 days from the date of issue of LOI ? Please strike off what
is not applicable

Note : Marks will be awarded to applicant either on ownership or firm offer or can arrange for LPG Godown/land for LPG godown based on the
information given by the applicant . On verification if it is found that the information given above is incorrect/ false/ misrepresented then the
applicant's candidature will stand cancelled and will not be eligible for distributorship.

13.2 SHOWROOM FOR LPG DISTRIBUTORSHIP

Showroom should be located in the location advertised and should have suitable approach road.
13.2a Do you have a suitable land within the advertised location preferably near industrial/commercial hub for LPG YES NO
showroom or LPG showroom readily available Owned/Leased (Minimum 5 years from the date of advertisement) in Please strike off what
your own name or in name any member of your ‘Family Members’/Registeres Society/Firm/Company(Select what is is not applicable
Note :(‘Family members’, shall consist of applicant, his/her Spouse and their son(s)/daughter(s), Father,Mother,Father in Law,Mother in Law, Brother
,Sister,Spouse's Brother & Spouse's Sister

If Yes to 13.2a, Provide the following details and attach affidavit if the land for showroom is offered by a Family Member/Firm/Company.
Land for showroom / showroom is in Date of registration of sale Relationship with Address of the land for Khasra no/ Survey
name of deed/mutation/gift /lease applicant showroom /showroom No.

If NO to 13.2a, then
13.2b Do you have a Firm offer of sales/ Lease (Minimum 5 years from the date of advertisement) from any owner of the YES NO
suitable land in the location advertised for showroom or showroom Please strike off what
is not applicable

If Yes to 13.2b, Provide the following details.

Land (for showroom)is in the name of Date of agreement to sale or lease on Address of the land for Khasra no/ Dimension ( L & B) in
or showroom in the name of stamp papers showroom /showroom Survey No. Meter

If No to 13.2b then
13.2c If you do not have a suitable piece of land for Showroom and do not have firm offer, can you arrange the same in the YES NO
location advertised,if selected within 45 days from the date of issue of LOI ? Please strike off what
is not applicable
Note : Marks will be awarded to applicant either on ownership or firm offer or can arrange for LPG Godown/land for LPG godown based on the
information given by the applicant . On verification if it is found that the information given above is incorrect/ false/ misrepresented then the
applicant's candidature will stand cancelled and will not be eligible for distributorship.

Name of location : Signature of Applicant

Contd. to page no.4

 APPLICATION FOR HPCL LPG Energy Solution Providers and Suppliers (ESPS)
(FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN)

14 Capability to Arrange Finance

Please note that marks will be awarded to applicant on capability to arrange finance based on the information given by the applicant on the Annual
Income, Amount in Savings Bank Account, Value of investments in FD/Shares/MF etc., and ability to get loan from Banks/Financial Institution. On
verification if it is found that the information given by the applicant is incorrect/ false/ misrepresented then the applicant's candidature will stand
cancelled and will be ineligible for this LPG ESPS/SSP distributorship selection.

14.1 Total Annual Income of Last Financial Year*: Rs.

Amount in words:

*Income from Salary,Property,Business,Agriculture,Royalty etc. pertaining to last Financial Year.

14.2 AMOUNT IN THE BANK*

Attach affidavit (to be given by the family member as defined in eligibility criteria other than applicant)as per format given in Annexure-A5.
The amount mentioned should remain in the bank for minimum period of 90 days from the last date of application or the LOI date which ever
is earlier.

S NO. Bank 1 Current Name of account Relation with Maximum Closing Balance*
Month and Year Account/S.B.A/C Holder applicant
1 M1 Rs .
2 M2 Rs .
3 M3 Rs .
4 M4 Rs .
TOTAL Average of Maximum Balance*of Bank1 Rs .
Total amount in words.

S NO. Bank 2 Current Name of account Relation with Maximum Closing Balance*
Month and Year Account/S.B.A/C Holder applicant
1 M1 Rs .
2 M2 Rs .
3 M3 Rs .
4 M4 Rs .
TOTAL Average of Maximum Balance*of Bank2 Rs .
Total amount in words.

S NO. Bank 1+2 Current Name of account Relation with Maximum Closing Balance* of Bank 1 and Bank 2
Account/S.B.A/C Holder applicant
1 Bank 1 Rs .
2 Bank 2 Rs .
3 Bank 3 Rs .
4 Bank 4 Rs .
TOTAL Average of Maximum Balance*of Bank 1 and Bank 2 Rs .
Total amount in words.
*Please attach the Saving account /current acount details of the last three completed months (M1/M2/M3)preceeding the month in which the

14.3 FIXED DEPOSIT/NSC/SHARES/MF ETC OF FAMILY Attach

affidavit (to be given by the family member as defined in eligibility criteria other than applicant)as per format given in Annexure-A5.

S NO. Type of Investment Document Reference Name of the Relation Initial Value ( Amount ) as on the date
FD/NSC/Share/etc. Number Holder with investment
applicant Amt.
1 Rs. .
2 Rs. .
3 Rs. .
4 Rs. .
TOTAL Rs. .
Total amount in words.

Name of location : Signature of Applicant

Contd. to page no.5

 APPLICATION FOR HPCL LPG Energy Solution Providers and Suppliers (ESPS)
(FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN)

14.5 Details of the loan which can be obtained from Schedule Banks / Financial Institutions based on Bankers / Financial Institution certificate to
extend loan as per Annexure A4
Name and address of the Bank / Financial institution Date of certificate Amount of Loan (Rs.)
/ /

16 Consumption of the customers where fuel conversion of Packed ND LPG has been carried out by the applicant.
Sr. No. Name of Industry/Customer PO NO/Work Order No. Date QTY (MT)

17 Experience in carrying our converison from other fuels to packed ND LPG-Details of Number of installations
Sr. No. Name of Industry/Customer PO NO/Work Order No. Date of completion QTY (MT)

18 Experience in ND Packed LPG Transportation & Handling of Packed LPG transportation done in the last financial year
Sr. No. Name of Industry/Customer PO NO. Value of Transportation

19 DECLARATION BY THE APPLICANT.

I am aware that inter se suitability of candidates will be decided by evaluation of candidates on the document based marks and interaction (
interview). Evaluation on document based marks will be done based on the information given by me/us in this application. On verification by the Oil
Company if it is found that the information given by me/us is incorrect/ false/ misrepresented then my/our candidature will stand cancelled and I/We
will be declared ineligible for LPG ESPS Distributorship. I also confirm that I am in possession of the supporting documents in original for the
information given by me in this application and if selected, failure to present these documents in original will result in cancellation of selection due to
submission of false/unsupported information in documents

I am fully aware that if I am unable to make Godown duly approved by the Chief Controller of Explosives on the land /godown indicated in the
application and or Showroom as per the oil company’s standard layout on the land/shop indicated in the application herein above after selection
then the allotment of distributorship made to me will automatically stand cancelled.

I am fully aware that I will not be appointed as LPG ESPS distributor if I am employed. I shall have to resign from the service and produce proof of
acceptance of my resignation from my employer before issuance of Letter of Appointment.

I have read the condition for the distributorship mentioned in the advertisement and confirm that I fulfil the eligibility criteria for the LPG ESPS
distributorship for which I have applied for in this application.

20 I, _________________________________________________________daughter of /son of/ wife of

Shri__________________________________ hereby confirm that the information given above is true and correct. Any wrong information
/misrepresentation/ suppression of facts will make me ineligible for this LPG distributorship.

Place Signature of applicant

DATE Name of applicant

(Name in block letters)

Name of Location___________ Signature of applicant

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